HomeMy WebLinkAbout0019 HUCKINS NECK ROAD - Health 19 HUCKINS NECK RD., CENTERVILLE
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SAY
mead
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UPC 12534 '
No.2 153LOR
HASTINGS,MN
No.
THE COMMONWEALTH F MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for Migonl *pztem Con!6tructgon Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No./ Owner's Name Address and Tel.No. �g(, d cl3— —),.I Qv
CN
Assessor's Map/Parcel 0),5 1 kO k S A C f PD A� I n
Installer's Name,Address,and Tel.No. Designer's ,Address and Tel.No. V �C
061
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder,(Oq
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank \C�Xb Type of S.A.S.
Description of Soil
��ature of Repairs or Alterations(Answer when applicable) h1{��1 n�,\ � fT�
Ck� �- `T�i �tn,r)R l
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Enviro a ode and not to place the system in operation until a Certifi-
cate of Compliance has been issuqQby this B of alth. G
Signed Date
Application Approved by ^ Date..
�T
Application Disapproved for the following reasons
Permit No. .®: Date Issued Y ''
No. i L Fee�V`" >
THE COMMONWEALTH F MASSACHUSETTS Entered in computer:
„ Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprtcatton for Mtgpogar *pgtem Con!5tructton ,Permtt
Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. q /lv`(k y,3 j) R_( a 9wner's Name Address and Tel.No. ( � d�3.. �� 3
Assessor's Map/Parcel !" O�^ ����,,�c�� tt
Installer's Name,Address,and Tel.No. Designer's 14ark,Address and Tel.No.
Type of Building: ,}
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(Nk))
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1�'�X7 Type of S.A.S.
Description of Soil
ature of 4epairs or Alterations(Answer when applicable) Al Lil C1 \krf,' Us sJ !CA ^A_
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Enviro evtaTCode and not to place the system in operation until a Certifi-
cate of Compliance has been issued''by this B a'd of alth. /
Signed /� Date � ' c1 f
Application Approved by Date F"/ 4 7
Application Disapproved for the following reasons
E
Permit No. Date Issued
—---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
T BARNSTABLE, MASSACHUSETTS
Certtftcate of CompItance
THIS IS TO CERTIFY, that theOn-site Sewage Disposal System Constructed( )Repaired ( V)Upgraded( )
Abandoned( )by c G�(\(\ j nn C,.r(-\
at S1 j.,r\ ' has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated"
Installer C-\ C r-tA k _ Designer 1
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date l - 2 - � 7 Inspector ` \. ,
4
---------------------------------------
No. 7- Fee
THE COMMONWEALTH OF MASSACHUSETTS �`�jJ s
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
MttpoZar bpgtem Congtructton Permit
Permission is hereby granted to Construct( )Repair( V)Upgrade( )Abandon(,
System located at 1 S1 kAt CIA rr 5 ti@ C.GZ S7 6� C.2.L �t r.)t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction
//must be completed within three years of the date of this it.
Date: ''" 1Approve '< �
I
NOTICE: This Form is to be used for the Repair of Failed
Sel)tic Systems Only
CERTIFICATION OF SKETCH ANU'APPLICATION FORA DISPOSAL
1VUitKS CONS]RUGHON I'1?10111 t1Vl'1'1[UU'I llCSIGNEll PLAN
1, Gy � \ hereby certify that the application for disposal works
�T-4
construction permit signed by me dated c�/ r�/ 7 , concerning the
property located at �Gl ���r� �C cl meets all of the
following criteria:
• Thcre arc no wetlands within 300 feet of the proposed septic system
Z-' Thcrc arc no private wells within 1 So feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
•� There is no increase in now and/or change in use proposed
There are no variances requested or needed.
DATE:
SIGNED: 4
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
,.
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s��
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6 �
c«wL
���5�.
TOWN OF BARNST LE
LOCATION
SEWAGE #
vn,LAGE V� ASSESSOR'S MAP & LOT�/ 7
INSTALLER'S NAME&PHONE NO.,, Q Tl h F'_MOIA
SEPTIC TANK CAPACITY I Q 0
LEACHING FACII.TTY: (type) L.1 f���- �t ����'S�S (size)
NO.OF BEDROOMS
BUILDER OR OWNER JUG, l Vr^w'zi
PERMITDATE: - I I l c. Gi�_COMPLIANCE DATE: C,,1 J 'A
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ' Feet
i Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) v Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
Within 300 feet of leaching facility) Feet
Furnished by
o °
v
79
�-- TOWN OF BARNSTABLE `
L le O'S meck-, SEWAGE #
`vTi ASSESSOR'S MAP & LOT 29- 0&2
`Kit sNAME&PHONE NO._ KcClCaZ( � �1� �8�°-7GQJ3
SEPTIC TANK CAPACITY __ to Do_�CA.,
y
LEACHING FACILITY: (type) x G t Fn L4
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: '31al d o
Separation Distance Between the: u
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or.within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by BSI
v
„ r
0
Il --
TOWN OF BARNST LE _
,
LOCATION `��!°t"i t n1`0 SEWAGE # "
VILLAGE �I��C� ��`"� c ASSESSOR'S MAP & LOT °- 6 7
INSTALLER'S NAME&PHONE NO.�CCSQ t1 f-t C—c ,,m 2 2z--s-b i4i
SEPTIC TANK CAPACITY J Q 00 c�C e �� Lzz,,( ` --A f
LEACHING FACILITY: (type) r,,Qc rc hrS (size)
NO.OF BEDROOMS, .
BUILDER OR OWNER - ca\r,, l V
PERMIT DATE: - I (c.\(4-':� COMPLIANCE DATE: f ��D
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility N6n` VFeet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 4)(3(\? Feet
Edge.of Weiland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
.4
z
3
lugCOMMONWEALTIJ OF MASSACHUSETTS
ExE'.CUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRCINMENTAL PRO'Y WnON
ONE WINTER STREET, BOSTON 1r(A 02108 (617) 292•5600
TRIM Cl.)XE
8scren;at�
ARG.R.0 PAUL C.ELLUCCI bAV1.0 B:SIX:INS
Gaysrnor Cotusirrintur
s4muRFACE 6EwA®E DpIFOBAL s1PST1m M16PEcmm Fow
PAIR A
CE111M4CATIOM
P1 epWW Addeaa: lei
1kV c.ti;hc h) etc trarrta d Owow �n C
C,ev� V tl a SS Ad ireftof Onsw
Doss aR Mespaotien: 3 d H✓e rt-�.er�i IL e ►+55. Oa bs��
NearsofY op.'I RYasa 11O.—�&aLW6
l e**a oEP ryopra ,paee�pr peasant es tii.340 of TWa 61310 CUR 16.0001
C lrlarita: 1 r v.,5 Gfirp-.S
Nltfal AddNies: ' 1A.! S Qp't(act I
Tdooh NwrAv:
�t�A_41 64/ATIBEIBIIT
I eortHy that I have parsonaily inspected tuts**wage disposal system at this addr set and that the information reported below is truly ecourote
and compieta ss of the dins of Inspection The Inspection was performed based on my training and experience in the proper fu nttici n and
maintsnsnee of on•ske sewage deposal a rstems. The system:
Passe
Conditionally Pesnea
_ Needs Furthor Evidustion By the Local Approving Authority
fails
taapaesar's fllgAsiawe: �� DNW. 6 Od
The Silstsrn inspector shall submit a copy of this inspection report to the Approving Authaft(Board of Wealth or DEP)witMn thirty(301 days of
_ eort�p lWg this Inspection. if the system Is a shared system or has a design flow of 10,000 ppd or greater,the inspector and the i ystorn uw.1 or
shun submit the report to the appropriate regional office of the Department of Envkonmontsl Protection. The original should bs tan r to tM
systoni owner and copies sent to the buy sr,If appiiosbla, and the spproving auttwity.
NOTE'6 AND COMMENT!:
s
RECEIVED -,
M A R 1 7 2000
TOWNURV Age ,
�. HEALTH DEPT
revised 9/2/98 1neIofit
H PORad on MK`rd ld PIW
`J,
I
i
SUMMACE SE1MAGIE DBIWOM S VSTEN WSPWr1ON FO11M
PART A
Cf71TfFfCAT10N fatttrtNsadl
prais ty Address: 19 O u`AL i Itn, IV c~ - W
owW": r f U>n'o r-
Dow of- -P allO11: 3 l at�00
MBliPwmn SUMMARY: cheat♦ A, & C, or D:
A. SYSTM PASM:
_ I have not found any infoemvion which indicates thst any of the failure conditions described in 310 CMA 15.303 exist, Any failure
criteria tat eveluatod are Ind.sated below,
S. SYSTM O0N101110NALLY PA SAIIII:
One or mere system components as described In the "Conditional Pass" section to be replaced or repaired. The oystam, upon
completion of the replacement or repalr,as approved by the♦card of Health, pass.
Indlests yea,no, or not determined(Y, N.or NO). Describe basis of dotannin n in all instance*. If "not determined explain why not.
The soot tank Is nhetat,unless the owner or operator t provided the system inspector with a copy of a C41rtiflc:ato of
Compliance(attteehad)indicating that the tank we ' stalled within twenty 1201 years prior to the date of III*inspections:or
the septic tank, whether or not metal,is crack .structurally unsound,shows substantial inflltration or ex;ifhratio,n,cu think
failure Is Imminent. The system will pass on if the existing septic tank is replaced with a compb,ing t.eptic tank as
approved by to®card of Health.
$swage backup or Noskou high static water level obsorved In the distribution box is due to broken iw iubutruetod pillw(s)
or due to a broken, sett) or uneven disMbution box. Thee system will pass inspection if(with approve;of tl!a Boa(, of
Health),
on p[Wel are replaced
obstruction is removed
distribution box Is levelled or ropiecod
The cyst required pumping more than four times s Veer due to broken or obstructed pipais). The system t.if peas
inapseti If(with approve"of the Sowd of Mooch):
Waken PIPS )are repkaoed
3batruet►on is removed
111sed 9/2/99 2or11
SIJBGURFACE SEWAGE DMOGAL,SYSTM NSPECTtOM FORM
PART A
C6ITtHCATIOsI IaeatYarad)
fra Address: f�t *v ck n ns NC ck W
Owner: �i u Ntal`D.
Daft off Inapsaew 3 k-,;L too
C. I4IRTt m EVALUATWM IS RIFO M D Sr TIN MN M OF HFrALTM-.
Cornditlons esdat which require further evaluation by the Board of Mealtln in order to determine If the system Is falling to of o ect the
public health, safety and the anaironment.
ty SYSTM MALL PATS 6dItLEM IIDAND OF HEALTH DEMUMS N AMORDANCE W11M 31016iR 1S.303 Itllbt li MA,T'rM 31!nal
is MT FUNCM MMD N A ip{pNNEIIII WHICH WILL PROTECT THE PIIN.IC HEALTH AND THE EUVIREMMINUM
Cesspool or privy Is Mrithln 50 feet of surface water
,q Cesspool or privy la within 60 feat of a bordering vegetated-made"
watt• or a ssit marsh.
2) SYSTEMS WILL FAIT.UNLESS T1 lE llIOA� LTH LAND PtISLIC rtlATta'R SUPPUE>iI.F ANY)INNS THAT TN,i:SY';STI]Ii IS
F1JgCCTIOa1Ml0 N A YAIsltEA 1'MA4 P" CTS THE PIJSIJC HEALTH Alto SAFETY AND THE EFt11 T:
,! The system has a septic to and$oil absorption system(SAS)and the SAS is within 100 feet of a surface iuvor supply ar
tributary to a surface sr supply.
The system has a a" tank and soil absorption system antl the SAS is within a Zone I of a public wetar supply well,
The system Pon s tank and sell absorption system and the SAS is within 50 feet of a private water supply wail.
The system has a ;tic tank and sell absorption system and the SAS is less than 100 fast but 50 two or morn from a
Ovate warm sat y well.unless a well water analysis for ociliforrn bacteria and volatile organic compounds Indicatss VM the
WON Is free pollution from that facility and the presence of ammonie nitrogen end nitrate nitrogen Is sgi4W to or Is as
than 6 ppm. used to determine distance _IMIIMoukrAdlen not v".
31 OTHER
revised 9/2/98 Pap3ofll
Si GUMFACE SEWAGE DISPOSAL SYSTSM MPECTIAN FORM
!PART A
CE71TVW-'ATM ho"looudl
11'"p«RY Arent. 0 ,yJt.�r1s5 C C K
Owner. l V 1"4J'0_
Oeas of hinspaallarr: z (2A Op
O, fIYST111111111 FARM:
You must indicate ahthw 'Yes"or"No" to each of the fallowing:
I have determined that one or rn era of the following failure conditions exist as described jnXIO CNIR 15.303. The Ussis fix this
datwminetion is identified belo>rr. The Board of Health should be contacted to dater what will be necess"to+^"ottein the fop urn.
Yes No
Backup of sewage Into facility or system component due tot erioaded or clogged SAS or cesspool.
Oischerge or ponding of effluent to the surface of the nd or surface waters due to an overioaded or clop pad'SAS;or
cesspool.
Static liquid level in tho distribution box abo outlet Invert dew to an overloaded or clogged SAS or cesspool.
Ll*dd depth In ees�C sl is leas than B" ow Inv*"or available volume Is less than It2 day flow.
_ Required pumping ma-s then 4 a in the lost year JW due to clogged or obstructed pipe(O.
Number of deer•pumi:�ed
Any portion of the Soli orption System.easapeal or privy is below eM high groundwsta elevation.
Any®wsia►of a e yiooi w privy Is within 100 feat of a suriaee water supply or tributary to a surface water supply.
Any portion a cesal,aal or privy is within a Zone 1 of a public well.
Any on of a Nati fool w privy is wkMn&C feat of s privet•wstet supply w@N.
A portion of a oealloci or privy is Iose•thon 100 feet but girestar than 60 feet from a private water supply we,it with no,
eeptoble water quality anelyals, If On well has been analyzed to be acceptable,attach copy of well water awdysiia 1Nir
eowwm bacteria, volstile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTW FA1LG:
You must Indicate either"Yes"or "No" ':a each of the fo6ewing:
The following crkeris apply to large systems in addition ctltarla above:
The system serves a faoglty whir a design Sow a 0,000 gpd or greeter(Large System)and the system is a signiflo re t'xeat:to pttbac
haaltf+and safety and the envir,mment becou area or Rare of the following conditions exist:
yes No
the system is within feet of s surface drinking wow sut*ly
the system is it00 het of•tributary to s at+rises dki++ikktg water supply
91re eyetem is sled in a nittrogan sansttive ores(interim WOW@"Protection Area='IWPA)or a mapped 2orre it of.s public
water wsgl
The rnrnw of opwatw of such syatum shall upgrade the system In accord* with 310 CMR 16.304(2). Pleas coneurt ttw local reiilional
ofticm of the Department for furtir«Information.
revised 9/2/98 Taas4of11
t
EiJOISURFACE SLWAOE DISPOSAL SYSTEIM 94PECTXM FORM
'ART•
CH@CKLWT
Owner: r t1�•ia('0�
1
sf lops", s
Check if the fakwbng have been done.YtrJ must indicate shher "Yes" or "No" at to each of the following:
No
Pumping information w u provided by the owner, occupant,or Sosrd of Healtt+.
None of the system components have ban pumped for at least two weeks and the system hen been recshinll nrarmal flim
rates durkV that period. Large volumes of water have not boon introduced into the system recently or as ipam coo this
inspection.
As built plans hove bean obtained and examinod. Note if they are not evellable whh NIA.
The faoWty or dwelNng was Inspected for signs of awago beet-up.
The system does not tv"ve non•sonitary or Industrial waste flow.
_ TM site was Inspected far signs of b►se out.
AN system components,excluding the SO Absorption System,have been located on the she.
The septle tank msnho es wwo uncovead,opened,and the Interior of the septic tank was inspected for conditle n of ba1?les
or two,material of oorstruction. d inonsions.depth of Wd.depth of sludge, depth of scum.
The ties and location of the Soll Absorption System on the site has been determined based on:
Existing irsBorraation. Ihx exempts,Man at•.OA
a Data,Ift d in the field(if any of the foliwe crltw i*related to hart C is at issue,approximation of distance llu w1w4optab+ai
+' 111.30213011
y The fooNity owner lend occupants,if different from owner)wars provided with Information on the proper rraleRrtone*of
'C SubSurfece Disposd S ystoms.
revised 9/2/98 itapsoftt
VASMACE SEWAGE 011 08"SYSTM MPECT10N FORM
PART C
SYSTEM 01FORMATODN
OWNS. u orc-t�
o.m� Iod
FLOW CONOmollls
De"M tow. Iry e.q'd. b! "
Numberbedroom of bedroo idaalgn��:3. Number of bedrooms(aewal)a
Tote!DESIGN flaw .
Number of current reatdemts:
Sande grktder(yes or no):
LwoW ry isaparete aystam) (yes or noll j�p If yes.sopotste Inspection required 3
Lwndl•y system Uspaated,jyps or no)
Seasonal use lifts or"*:O6 j[
Watef meter readktgs,If ebie Usti two year's use"(gpol: r 1 -ell
Swap Pump Iyea or noi:10
Lost elate of occupancy:
Type of establishment:
D"91 flow: ad 1 Sssad un 16.203)
Sods of design flow —• ——_--
Oros@*trap present:(vas or no)_
Mdust:rial Waste Holding Tank prosont:Ivh» no)�
Non-earkary waste discharged to the S System: lye* or no)_
Wow meter readings.If eveilable
Lost date of occupancy:
OTHER:(Descr")
`eat date of oe*up _
_J
_t G�l�uu.M�OIOIMATfON /�?c J_!�
MOM and e se
d/ d" G ( ' Aq-Lq, q 6
3yatern pumped es pert of In ivetlon: (yes or no_)_ � V
/�
If yes, volume phi mped
Reason for prmping: l
OF SVISI
_ Septic to Wdistribution box1soil absorption system
Single cesspool
Overflow Cesspool
ivy
,. Shared system Ives or not (if yes,attach previous inspoction records,if any)
VA Technology*to.Attach copy of up to date operation and ensintenaince contract
TigTrf Tank Copy of DIP Approval
AFftlIIDXMATE AGE of all components, i,Wte instalied(if known)and sour**of information: 4�
$swa >o adore detteW when arriving at the site:(yes or no).�
revised 9/2/$8 Papo6of11
S UNSURFACE UWAGE 011014 SAL SYSTEM ONPEC1i0M FORM
'ALIT C
/YSTEM goomuTm Ioannina"
o+a�: „yam
o.I.of tlMt#wftss� �p .
sue:
(Lo"s an sits,plan)
r
Depth below grade;
Material of oaNt ruction:—cost iron i 4o PVC—other(explain)
Distaree lyIvats water supply WON cn auetlon one
Dlarreter
Comments:loondlion of joints,venting, mvidenco of leakage,etc.)
SPAC TAM-
liocato on sits plan)
Depth below tirade:
Material of aOnst►uction: Looncrete_njetal_Fiberglass _Polyethylens_otherlexplain)
If wA is metal,not age��, Is age corArmed by Cod as of Compliance (Yes/No)
Dkftan1""! 000
SWdgn depth: n
Owence from top of Idgs to bottom at outlet too or baffle:�
ftur"thickness:,tl I,,,_ 1!
bisaancs from top of scum to top of outlet tee or belle: p
r Dletwee from bottom of scum to bottom of Outlet or beffloi—a
I-- ..
.. .•law cbnaeions ewe determined:.4Ar
Comments:
freconwoondation for pumping,inp011on ffJrtlet nd outlet tees or balsa depth of liquid level in relation to et invert.Structure.into'NryY,
evidoroe f 1}elago, .) `T rdAz jt i f �n_c9 t~•��j f uJ a' Pt��.3.
OIIroAflE
(eooate on site Ow)
Depth beta grader
Matiwid of construction:,cconereta_metal,,,.,Fiberglas _,Polri elf'e,,,.otherlexplaln)
DMnenelae: �_
gown MItkness:
Distarme from top of scum to top of outlet tee or
Olatmoo from bottorn of scum to bottom of tea a beflla:
Doles of last ptxnping:
Carwnonts:
(recorrumndetion for pumping,c on of inlet and outlet tees or beffles,depth,of liquid level in relation to outlet Invert.struoctural Intelprk:y,
evidence of leakage,oft.)
revised 9/2/98 ragrtofit
lUNURFACE SIEWAGE OWPOM sr 151111■ SPECT10N FORIA
►MeT C
SYSTIEM SEOfIMATION(eertfirarad)
A.�. P°I Wacki-tj O&L Qd
new PAI
Omme erR moms""'°: 3 f a t 0a
TIW'011 NOLAW TANK: ITank mmust be purnpod prior to, or at theta of, inspection)
Ileea s an oft Owl
Dome bSlow raft:�
Mat lei of oorwoustion:_Consrote_0401111_ e►®lase_potyathylano_othertexplein)
ONeeeralerts:,�_ '
�°"s
Deaw t flow: 9 No"U
Akers"present
Aterrm ketni:®Alm we►kfee9 order:Yes_ No—
oate of previous pumpl►ep:
Ca"OWnts:
laonditlon of irdet tee ondidon of slanm and most switches,etc,)
am"OUTM Nom"f
florae on wee plate)
tDep�t► at tisuld bvol above outlet invem.
ceeett+taetcs: ,
(note It 11"end di 'but *Wql,evidence of solids corryover,ovidenca eskape Mtp Qr outer box atc.?
mocLiL -�QeJ Gti K 7"-Cr t
PUM
(knee an else plsxt)
f+te"tps In w *l;Vq erdw:(Yes or No)
ANrms in wattdng order(Yes or No
Carrmterete:
(emote oondMion of pun*ch eondh an of pumps and appurtenancee,etc.)
revised 9/2/98 hip 8ofit
r
SIMSURFACE SEMIIAQE DWPOSAI SYSTEM WSPECTION FOAM
PART C
SYST713A SW*RMTM lcemdnLvdf
. �► �� M-b&S kkck
D �.
orm: i L)MkAPu
D.w of blowtift � j 0.1
atoll.Il�tolM�o«sr�Taio fsAs►:.,�
poo&%on site plan.It possihb;excevsdorI not rotlubed.loostion may be approximstod by non-Intrusive mwthodsl
If not boated,iapWn:
Typ.. feechh pits,nun*w:
eharnbsrs,number:
bechMq ssasrlss,number.—E
wee"trsnehes,numbs,
Ieeah'i 9 Adds.nundwo d inensinns:
overflow cesspool,narnbw:_.
Alternedvo system:
Flame of Technolo":
Cemnrrnts:
(we condition o4 sell,clans of hyd wile I:tiiure,i wl of pondino, ds roil,oorwAition of veQotedon, }
7-6
cesspo=:r
(boats on sits plsn)
Umber end conOWntlon:
'""estop of No"to Wet Invert:
*pm of scads layer:
uepth of seam It":
DWw"dons of cesspool:
aetalNs of ,
Ind estron of Sr
inflow t sspool must be pumped as part of inspeotloal
ComnrtnRs:
(note condition of soil,alone of hv*wAc Iamurs.level of pond no, condition of vegetation,etc.}
_
noes"er,slte plan) /
Metabtls of construction: Obnonslons:
Depth of solids
Co+remrrKs:
(note condidw of loll. •of hydroubc"alkwo.level of ponding,eondhion of v"Notion,oft.)
revised 9/2/98 Pap9oru
1elist RFACE SEWAGE DISPOSAL f1 STM SUMOCT101111 FORM
"me
IVSTEM MFOIMEATM 40W111M984
Deft tot 91
SFCE C"OF 1111IIrAN DISPOSAL sYMM:
kaoFude floe to at Fast two pennenont reference londmwks or benchmarks
Maw all waits within 100'ILa:ate whore public wetw supply toms@(into house)
0
�o
� L
r
revised 9/2/98 ►W10of11
(Y
1 � i
lVslUIWACE SEWAGE DISPOSAL 11/ITEM ftlPECTM POWM
PART C
*TSTEM SWORMATIOMI taenenuadl
I'Veparl7• : l vc ki�s 10� PIQ
owwtr f't oilCIAL
Deft sal'brpamlert: �6a ldO
NRCs Report"Pole
Sol Type_
T"UM depoh to groundwater+
uses Dots wallah Visited
observation Walt Checked
Groundw W depth: $halo*_ Moderate
SITE EXAM 91411e
surface wow
Check Caller
llralow weft
Estimated Depth to Groundwater r�Fee,
Pktaes 6ndicam all the methods used to des anydne Nigh Groundwater Elevatlon:
l� Obtained from Cosign plans an reea d
Cl beerved Site(Abutting property.*I servetion hole,basement sump eta.)
vetsrmined tram leoel condi m
Checked with Iona Board of health
Checked FEMA Maps
Chocked pumping records
Checked local excavators,installers
Used U806 Dan
Deserihe how you esioNshed the Hish Groundwater Elevation. IMM be completed)
� `� '�g Q ►� t-� bud cn�
revised 9/2/98 hgrtiaftl
�s BARNSTABLE COUNTY
DEPARTMENT F MAN O HEALTH, HUMAN SERVICES AND THE ENVIRONMENT
SUPERIOR COURT HOUSE --
- • BARNSTABLE,MASSACHUSETTS 02630
• • Phone:(508)362-2511 Ext 330
R'SS Public Health Administration 333
Environmental Health 383
Water Quality Analysis 337
Human Services 330
TOD 362-5885
v.0 Sly>/
LETTER OF LEAD PAINT (RE) OCCUPANCY (RE) INSPECTION CERTIFICATION
UNAUTHORIZED DELEADING
Date: Sept. 24, 1993
Dear Mr. Fiumara• ,
This letter is to serve as notification that Ia (re) occupancy
. (re) inspection was performed at �-19-_uck'ns N rk Rnad_*'�
in the City or Town of Genre"v 'lie, MA. aridalr applicable
common area and. interior }surfaces have met the conditions for
(re) occupancy set in 105 CMR 460 . 760 (A) . This notice does not
constitute deleading compliance.
Prior to the (re) occupancy (re) inspection, all sanding was
completed and-no, additional sanding will be permitted following the
clean-up provisions required by 105 CMR 460 . 160 (D) No other
. interior abatement may, occur unless the conditions of 105 CMR
460 . 160 (A) through (E) are repeated.
This letter. certifies that on Sept. 15, 1993 no violations of
the Lead Law exist in the interior of the dwelling unit, relevant
common areas and exterior. NO FINAL LETTER OF LEAD ABATEMENT
COMPLIANCE WILL ISSUE ON THIS PROPERTY DUE TO UNAUTHORIZED
DELEADING. ALL OR PART OF THE WORK . PERFORMED TO CORRECT LEAD
HAZARDS WAS NOT COMPLETED BY A LICENSED DELEADING CONTRACTOR AS
REQUIRED IN 105 CMR 460 . 110 (D) . A complete clean-up in accordance
with 105 CMR 460 . 160 , by a licensed deleader (invoice for clean-up
attached) was performed on 8/27/93 r by John Kovach
license # DC000561
Massachusetts law does not require the abatement of all residential
lead paint. The residential premises or dwelling unit and relevant
common areas shall remain free of violation of the Lead Law only as
long as there continues to be no peeling, chipping or -flaking lead
paint or other accessible leaded .materials and as long as covering
forming an effective barrier over such paint or other leaded
materials remain in place. See the reverse side of this letter for
the location(s) of surfaces which were covered to correct lead
hazards, if applicable.
sincerely,
CJIdJZ�2 DH
9
Inspector license #
INSPECTION AND ABATEMENT HISTORY
Name and License Number of Inspector who performed Initial
Inspection (if anv) Douglas Williams #11843 8/27/93
Abatement History (.extent and method of unauthorized deleadina
deleader clean-up)
Removed garage door
Enclosed / ally.columns. with ply wood
Clean up and disposal done by John Kovach 8/27/93 #DC000561
AREAS WHERE -LEAD PAINT OR OTHER LEADED MATERIAL HAS BEEN COVERED AS A
LEAD ABATEMENT METHOD.
INTERIOR
R-oom No. - -
(As indicated on'initial
Inspection Report) Side Surface or Fixture Tue of Covering
--------------
EXTERIOR
Side Surface or Fixture Tvpe of Cove-iiig
JOHN KOVACH BUILDER
DELEADING CONTRACTOR
Lic. #D.C. 000561 vt
135 ChIppingstone Road rt
Marstons Mills, MA 02648
(508) 428-6139 >'
ABATEMENT _OMP T,T A?`T� T n rn r r•e+
To Whom. It May Concern:
WI&ve (.caPated the surfaces cited by
n a Lead Paint Inspection, conducted
on7_�Z at the property located at :
-owned by
All abatement was done in full compliance with
Department of . Labor and Industries regulations 454 CMR
22 . 00 and Department of Public NAalth regulations 105 CMR
460 . 160 items (A)' through (D) including the specified use
of a HEPA filtered vacuum. y
The job was done for the price of- $
DO 0_�2/
9
De ,�ea der License .Number
Date
t
n 40aF .
-}}-
YES I
NO
SEM
'SOUTH EASTERN MASSACHUSETTS 0a� -7 Z
HOME INSPECTION SERVICE
14 Nelson Lane, Marstons Mills, MA -02648 (508) 428-3562 TOLL FREE 1-617-230-5389
Inspected Property
Address
-1-r' � V � 1 ✓}1/Ji ��i fF1-'-�
S �
Owner (last name) r (first) (mid
Address
J
none: the owner is requ ed ldCfile with a 11, mor t gage'es f in: u olat10n .
Client
Client Address
I have recie s report
Inspection Date ,> I Inspector: Douglas L. Williams, Sr. Inspector License # 11843
Method of Inspection: ❑ Na S 0 X-Ray; Model # Serial #
ex:p date
Floor _- %-u Floor L%Oen
C.... ... ... .... .... ... ..... .... ... ..... ..... ... C.................... ..... ...... . ..
t .
PA LL:
:......:......:......:.......
B .:.. ..:.....:.... : ......
,1
.....:..... .........:...... .....:..... :. ... z.... :....
,.
.....:......
�... ................................ .. .. .. .. ..
... ..
A (Street Side) ' A (Street Side)
PLEASE NOTE THE ATTACHED RIGHTS TO OWNERS AND TENNANTS
{ Pb = lead cov = covered rev = reversed
1 Neg = Negative scr = scraped comp compliance
na = not accessible rep = replaced
Pb=more:than 1.2mg/cm' with X-ray fluorescence or positive with NarS is ILLEGAL Pa e of
�, . .9
/'SEM
SOUTH EASTERN MASSACHUSETTS
HOME INSPECTION SERVICE
14 Nelson Lane, Marstons Mjtfs, MA 02648 (508) 428-3562 TOLL FREE 1-617-230-5389
KITCHEN pmvmy )tip
SIDE SOURCE Pb LOOSE COMP. COMP' SIDE SOURCE Pb LOOSE COMP. COMP.
DATE METHOD DATE METHOD
f Lower Walls CD Upper Wells a1 r� l d✓ ;
U per Walls — Lower Walls
Chair Rails Chair Rail
C I Baseboards — La C I Baseboards
Door
Door
Door/ Casin /Jamb — Door/ Casing /Jamb
1 Door Door
/ Door/ Casin /Jamb — Door/ Casin /Jamb
Door"
oor Window Sill/Apron —
Door/Casin /Jamb — ^ Casin / Header/Sto
oor I C Sash/Mullions
Door/Casin /Jamb r Exterior Sill/Part Bead
QDoo,
00r Exterior Side Sash -
Casin Jnmb Upper Cabinets
indow Sill/Apron Upper Cabinet Walls
WE
/'Header/Sto Upper Cabinet Shelves
Sash /Mullion — Lower Cabinets
naL
ior Sill/Part eadtower Cabins elvesrior Side Sash Shelves
w Sill/A ron Drawersn / Header/Stop floor C rf CV/Mullion Ceilin
ior Sill/Part Beadior Side Sashw SIII/A ron/ Header/Sto/Mullionior SIII/Part Beadior Side Sashw Sill/Apron
Casin / Header
Sash /Mullion
Exterior sill/Part Bead BATHROOM
Exterior Side Sash
C/ —Up p er -Cabinets_—_ U er Walls
C U22er Cabinet Wails fi�C Lower Walls .I4
CI Upper Cabinet Shelves — Chair Rail
F Lower Cabinets _ Baseboards
CI Lower Cabinet Walls Door
Lower Cabinet Shelves Door/ Casing./Jamb
r Drawers Door
Closet Door Interior Door/Casin Jamb
Closet Cnaln /Jamb Window Sill/Apron
Closet Walls Casino / Header/St
o
Closet Baseboard Sash /Mullions
Closet Shelves
Floor Vq r Exterior SIII/Part Bead
Exterior Side Sash
Collin Upper Cabinets h {
D Lower Cnbinets �Q7 h
Lower CabinetShelvea
Shelves
Closet Walls
Closet Door Interior
Closet Casino /Jamb
Closet Baseboards
Closet Shelves
Floor TI
Ceiling
Pb more than 1.2mg/cm' With X-ray fluorescence or positive with NarS is ILLEGAL Page —7 of
i C�t •
V EM
SOUTH EASTERN MASSACHUSETTS
HOME INSPECTION SERVICE
14 Nelson Lane, Marstons Mills, MA 02648 (508) 428-3562 TOLL -FRE-F, 1-617-230.5389
ROOM/ ROOM /� cont'd.
SIDE SOURCE Pb LOOSE COMP. COMP. SIDE SOURCE: Pb LOOSE CAP' CAMP.
DATE METHOD DATE METHOD
Lower Wells Window Sill I Apron
upeer Wells Casing Header Slop
Chair Rails Sash I MVIIion5
Baseboards — Exterior Sill/ Part Bead
Door Exterior Side Sash
Door/Casing /Jamb -, Window Sill Apron
Door C g' sin Header Stop
oor asin /Jamb Sash Mullions
oor Exterior Sill Part Bead
Exterbr Side Sash _
Door Window Sill Apron
Door I Casing Jamb. Casino / Header Stop
Window Sill Apron *' Sash Mullions
Ce in Has r stopExterior-$III/Part Bead
__jaLh.LM4IIIqn9 Exterior Side Sash
Exlerior Sill/P e d T- Closet Walls
rior Side Sash Closet Door Interior
Window Sill I Apron Closet Casino Jamb —
I Casino Header I Stop _ C Closet Baseboards
Saah .Mullions Closet Shelves
Exterior SillI Part Bead- Floor Cri,2
Exterior Side Sash Ceiling
Window Sill A ron - Shelves
Casin Header/Sto - Montle
Sash Mullions
Exterior Silt Part Bead
Exterior Side Sash
Window Sill Aron
•Caain Header Sto
Sash/Mullions'
Exterior.Sill/Part Bead
ExteriorSide sash BATHROOM
� Closet
Walls
Closet Door Interior Lower Walls
Closet Casing Jamb C Upper Wells
Closet Baseboard Chair Rails
Closet Shelves CQ Baseboards
F r {- — Door
Collin Door/Casing Jamb
Shelves Door
Mantle Door Casing /Jamb
Window SIII/Apron__ -
G Casing / Header/Sto
C Sash Mullions
Exterior SIII Part Bead
C- Exterior Side Sash
1i Upper Cabinets nter
t Lower Cabinets
Lower Cabinet-Shelves
ROOM / Shetvea
Closet Walls
L or Walls Closet Door Interior
Lower Walls Closet CasingJamb
Chair Rail, Closet Baseboards
f Baseboards Closet Shelves
G oor .% Floor
C r C i J
Door ( _ Collin
Door L Casin /Jamb
Door
Door / Casino /Jamb
Door
/77 Door / Casin / Jemb
Window Sill I Apron
Casino Header I Stop
Sash I Mulliona
Exterior Sill Part Bead I
Exterior Side Sasi�—
With,<X-ray.fiuorescenoe or positive with NaS is ILLEGAL . Page of
YSEM
SOUTH EASTERN MASSACHUSETTS
HOME INSPECTION SERVICE
14. Nelson Lane, Marstons Mills, MA 02648 (508) 428-3562 TOLL FREE 1-617-230-5389'='
ROOM /,3 ROOM ! S cont'd.
SI®E SOURCE Pb LOOSE DATE METHOD SIDE SOURCE Pb LOOSE GATE METHOD DATE METHOD
Lower Walls
C Upper Walls — Casln Header Stop
Chair Ralls
sash/Mullions
e and SII Part Be*
oor xterior de ash
o r Casing amb. WI ill Aron
Do
as n Bader to
Casino Jamb — ulllons
oor erior Sill art ad
IF
In Jm r le a
Door CI Walls
closet oor Interior —
Window Sill A ro Cios t Casin Jamb
CasinoHeader o r Closet Baseboards
Sash Mullions WO Closet Shelves
Exterior SIII/Part Bead Floor
xterior Side SashCalling
Window SIII A ron Shelves
Casin Header Stop Mantle
Sash Mullions
Exterior Sill/Part Bead
xt for Side Sash
Window Sill Apron
Casino Header Stop
Sash on Mu Ms ROOM
/
Exterior SIII Part Dead
Exterior Side Sash Lower Walls
par Walls -
Casino Header Stop Chair Rails
Sash/ Ii seboards
Exterior SIII Part Bead Door
xter or i e Sash Door Casino Jamb
Closet Walla Door
Closet Door Interior Door Casing Jamb
Closetina /Jamb Door
Closet Baseboard Door Casino Jamb
Closet ShelvesDoor
Floor 2E. - Door Casing /Jamb
Collina Window SIII Apron
Shelves asin Bader Sto
MSnII Sash Mui on
!eor'e i
art Dead
Exterior Side Sash—
Wlnd2V SIII I Aron
asin Header 3to
S Sash Mullions
ROOM Exterior Side Sash
Exterior Sill I Part Bead
Upper Walls Window Sill Apron
Lower Walls Ca In Header Stop
Choir Rail Sash / ullions
Baseboards — Exterior Sill I Part Bead
Door Exterior Side Sash
Door I Casino Jamb )ron
Door Casino Header Stop
Door Casino Jamb Sash I Mullions
13 Door Exterior Sill Part Bead
Door CasinoJamb xter or de as
Door Closet Wail$
Door Casino Jamb !212501 Door Interior
G Window Sill Apron —
Closet Casin Jamb
Casino Header I Stop Closet Baseboard
CL Closet Shelves
SashMullions — Floor C e42 41f_
Exterior Sill I Part Bead Collin
C Ext riQr Side $4*h helves
f ill Apron —
In Header Stop
hI Mullions Exterior Sill I Part Bead
/ I Exterior
Pb more than 1.2mg/cm' With X-ray fluorescence or positive with Na,rS ]s-ILLEGAL Page of
rSEM
SOUTH EASTERN MASSACHUSETTS
HOME INSPECTION SERVICE
14 Nelson Lane, Marstons Mills, MA 02648 (508) 428-3562 TOLL I'REE 1-617-230-5389
ROOM I 1gvn d lz -4t ROOM i - con4'd.
COMP. COMP. COMP. COMP.
SIDE SOURCE Pb LOOSE DATE METHOD SIDE SOURCE Pb LOOSE DATE METHOD
Lower Walls Window Sill Apron
Upper Walls Casing Header Stop
ChairitSash I Mullions
Baseboards Exterior Sill Part Bead
Door Exterior Side Sash
14- Door I Casino Jamb Window Sill Apron I
Door Casing/ Header/Sto
Door CasinoJamb Sash Mullions
Door Exterior Sill Part Bead !
Door Casino Jamb Exterior Side Sash
Door Closet Walls _
Door in mb Closet Door Interior
C- Windpw Sill I Apron Closet Casino Jamb
er/St o Closet Baseboards /
Sash Mullions C Closet Shelves /
Exterior Sill/Part Bead �. Floor /
Exterior Side Sash Ceilin 1 /
W Shelves
C Mantle
Sash' Mullions Me
ad 1
Exterior Side Sash
Window Sill/Apron
Casino Header Stop
Sash / Mullions ROOM
Exterior Sill I Part Bead
Exterior Side Sash Lower Walls
Window Sill I Apron Upper Walls
Casing.j.Header I Stop Chair Rails
l ions Baseboards
Exterior Sill Part Bead Door
Exterior ide ash Door Casing Jamb
Closet Walls Door
Closet Door Interior Door Casino Jamb
Closet Casino Jamb Door
Closet Baseboard Door Casing Jamb
Closet Shelves Door
Floor -✓ Door/ Casino /Jamb
Ceilino Window Sill I Apron
Shelves Casing /Header/Stop
Ma le Sash Mullions
U JIvL C < 0 V Exterior Sill/ art Bead
/ Exterior Side S sh
Window Sill Apron
Casing / HeaderV Stogy
Sash Mullions
ROOM Exterior Sill Part ead /
Exterior Side Sash
Upper Walls Window Sill/A ron
Lower Walls / Casino Header S
Chair Rail Sash/ Mullions
Baseboards Exterior Sill Part Beall
Door I V Exterior Side Sash
Door I Casino J. mb Window Sill/Apron
Door Casino Header Slob
oor .Casin J mb Sash/Mullions
Door Exterior Sill Part Bed
Door Casin J and xterior ide ash /
Door Closet Walls /
Door CasinoJa b Close Closet Casing /Jamb
Door Interior
Window Sill. Apron Closet Baseboard
CasingHeader StopCloset Shelves
Sash Mullions Exterior Sill Floor Part Bead Floor
Ceiling
Exterior Side Sash Shelves
Window Sill Apron Mantle
Casino Header/Stop
Sash Mullions
Exterior Sill Part Bead
Exterior Side Sash
.. 1'�Ti.:.�i3 ,,. � try. Fes,`.•+_ . j
Pb more than 1.2mg/cm= With X-ray fluorescence or positive with Na=S 1s ILLEGAL Page. of
� SEM �
SOUTH EASTERN MASSACHUSETTS
a
HOME INSPECTION SERVICE
14 Nelson Lane, Marstons Mills, MA 02648 (508) 428-3562 TOLL FREE .1-617-230-5.389
HALL I HALL 2,
SIDE SOURCE Pb LOOSE. COtrtP. COMP' SIDE OOMP CAMP DATE METHOD SOURCE Pb LOOSE
7F3(r--> UpperWalls c) r Walls DATE METHOD
Lower Walls Lower Walls
Chair Rails Chair Rails
Baseboard
Door Baseboard
Door/ Casin /Jamb Door _
2 Door/ Casin /Jamb
Door
Door/ Casing /Jamb Door
.� Door _ Door/ Casin /Jamb
Door
Door/ Casin /Jamb 1 Door/Casin /Jamb
Door Door
LVExterior
asin /Jamb Door/ Casin /Jamb
ill!A ron Window Sill/A ron
Header/Sto Casin / Header/Sto
ullions Sash / Mullions
Sill/Part BeadExtSide Sash Exterior Side Sash
Closet Walls Closet Walls
Closet.Door Interior Closet Door Interior
Closet Casin /Jamb Closet Casin /Jamb
Closet Baseboard C Closet Baseboard
Closet Shelves - Closet Shelves
Floor NAL F
Ceiling loor
Ceiling _
CrF1�? m
STAIRCASE STAIRCASE
C Upper Wells
Upper We s
Lower Wells
Wall CasingLower We[
Chair Rails all Casin
Treads Chair Rails
C Treads
Risers C r2 =001 Risers
Railing Cap Railing Cap
Handrails
Handrails
Balust ers
Balusters
Newei Posts Newel Posts
Strin of V Strin A-
boards Baseboa s
Window Sill/Apron Windo Sill/Apr n
Casin / Header/Sto C in / Header Sto
Sash / Mullions ash / Mullions
Exterior Sill/ Part Bead — Exterior Sill / Part ead
Exterior Side Sash—
C, poo------------- —_ Exterior Side Sash
Doo
oor
Door r / Casin�t 1 Jarnb _ — or / Casing / Jam
Door
Door Casing/ / Jemb
Ceiling
- -- Door / Ca /Jamb
Ceiling
Pb more than 1.2mg/Cm7 with X-ray fluorescernce or positive with Na,S ,is .,I:LL,EGAL Page of.
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